Annual Conference, Off to Vegas for an HIV PrEP Training, & Our Team is Growing (and Hiring!)A letter from the staff at NaRCADAt NaRCAD, we're getting ready for our busy season, which lately, has become a season that lasts all year long. And we're happy for it--because that means we get to help more programs across the US and Canada figure out the most impactful ways to use academic detailing to promote sustainable change. Whether public health programs are looking to increase prescriptions of HIV PrEP for patients at high-risk, encourage more referrals to nutritionists for patients with diabetes, or improve access to treatment for people struggling with opioid use disorder, we're there to help them, from program conception to implementation and evaluation.

Our next stop is Las Vegas, to work with the Southern Nevada Health District on improving outcomes around HIV prevention this December. (And for once, we hope that "what happens in Vegas" doesn't "stay in Vegas"; our goal is to increase visibility and prescribing of HIV PrEP so that more clinicians everywhere are reaching the patients who need it most.)

We've been staying busy here at NaRCAD this spring! With public health challenges like the opioid crisis, and the continued need for HIV prevention, the team here at NaRCAD has been on the road for 5 trainings in 6 weeks, and we're not stopping yet!

​Hosted in San Francisco's South Market neighborhood, 31 trainees attended, representing diverse public health departments from Texas, Connecticut, Alaska, Louisiana, Florida, Tennessee, Los Angeles, San Francisco, Mississippi, Michigan, Oregon, Nevada, Virginia, and beyond. These trainees joined the institute for a customized, 3-day event focusing on learning the techniques of academic detailing, along with showcasing best practices and success stories via special presentations and expert panels.

Upon identifying counties and cities with the highest burden of fatal and non-fatal opioid overdose and high prescribing rates, the CDC selected Bell County, Kentucky; Boone County, West Virginia; Manchester, New Hampshire; andDayton, Ohio as 4 pilot sites in which to convene with key community stakeholders and roll out community action plans, along with targeted academic detailing interventions.

Our work has involved launching on-location trainings at each of these pilot sites, focusing on providing front line clinicians with tools and support to improve outcomes for patients.

Messaging and support for these campaigns include lowering prescribing rates, referring patients to treatment for opioid use disorder (OUD) including Medication Assisted Training (MAT), and using their state's PDMP (Prescription Drug Monitoring Program) to identify troubling patterns of use, which may, in turn, help to identify those patients who need more support and care.

​Our pilot site trainees walk away from our trainings ready to actively engage with clinicians to assess individual needs and provide customized support, and encourage behavior change for the opioid crisis in their respective communities.

NaRCAD's team will continue to focus on launching new academic detailing interventions across the U.S. well into 2018, with upcoming opioid-specific trainings being carried out in late May in Albuquerque, New Mexico, with the University of New Mexico's Health Sciences Center, and in late June in Lansing, Michigan, with the Michigan Public Health Institute.

Our next all-topic, AD techniques training in Boston will kick off at the end of this month, where we'll train 24 health professionals from across the U.S.--we'll report back after that training and share lessons learned, highlights, slide decks, and clinical topics from represented programs, and we look forward to sharing those with our community.

Join our subscription list to receive alerts for upcoming training opportunities. Want to customize a clinical topic-specific training for 15 trainees or more, on site in your community? Reach out to us to schedule a training consultation call at narcad@partners.org.

Our AD program is part of a 3-year demonstration project (CDC Project PrIDE), and as part of our grant-funded work our overarching goal is increasing PrEP access and prescribing to MSM (men who have sex with men) of color and transgender persons who are at substantial risk of acquiring HIV. Our goals include improving sexual health in the primary care setting, refining sexual health history-taking, increasing screening and testing for those with risks, promoting best practices around PrEP prescribing, and helping to establish relationships between our health department and our community providers.

​​The added benefit of public health detailing is that it also increases awareness about the issues that affect our community. I have been inviting clinicians that I meet to join us in our city-wide Getting to Zero consortium, which helps providers feel that they are part of this important movement of preventing HIV transmissions, deaths, and stigma.

In San Francisco, there is a need for urgency around this issue, especially because it’s become evident that as HIV transmissions continue to decrease, the disparities among new HIV positive diagnoses become more apparent. Many of these disparities are among communities who still may not be aware of PrEP, or are facing barriers to access. Our academic detailing program strives to reach the providers who work with these vulnerable communities.

When kicking off an intervention such as this, identifying the clinicians who see this target population is the first step. To do this, we used STD surveillance data to determine which providers and clinics were diagnosing syphilis and rectal gonorrhea and chlamydia, which are associated with an increased risk for HIV. However, since many providers are not performing appropriate screenings, we also reached out to clinics known to serve our priority population and those located in neighborhoods with the highest HIV incidences.

The next step is how to “get in the door” with these clinicians, which means finding a way to secure a 1:1 visit. I’ve found that initial non-responsiveness isn’t the end of the world—persistence pays off, so keep trying to get in the door, or find an entry point through other community contacts. Sometimes, choosing a different access point can really work well to start a relationship. There are many places where 1:1 visits aren’t feasible due to clinic structure or culture. If I’m able to detail to a small group, it can be a way to meet with a few providers and gain insight about how PrEP might be incorporated or enhanced in their setting.

Being invited to an all-staff meeting is often an excellent way to kick off an introduction to this important intervention, and can result in follow-up conversations with individual clinicians. One benefit of meeting in small groups is that if a clinician hears a fellow clinician say that he or she is already prescribing PrEP, there may be more openness to discussing the topic; other providers might feel comforted in having a PrEP "ally", resulting in buy-in from the clinic overall.

Some clinicians may think that this type of intervention isn’t relevant to their patient population; as I detailer, I often hear responses such as, “I don’t see this population reflected in my practice,” or “My patients don’t have this risk,”, even if it’s been proven that these clinics do, indeed, serve priority populations. In order to talk about PrEP, you first have to talk about risks for HIV, which often means talking about sex. I think there can be discomfort on both the patient and provider side, and sex is often still a stigmatized topic. There are also overarching resource barriers, including the fact that clinicians are extremely busy and have to address competing health needs in the primary care setting.

While a small pool of clinicians have minimal understanding of PrEP, and require a basic overview about elements like identifying potential PrEP candidates, how to take a good sexual history, and how to bring up PrEP in an appointment, I’ve found that many clinicians are aware to some extent about PrEP already, and are interested in next-level details about how to implement it. This might include what kind of testing is recommended, how to increase number of basic screens, and increasing their knowledge about comprehensive health.

There are also providers who are very advanced in their knowledge of what options are available to populations with risks for HIV. This is where the academic detailing becomes more intricate; some providers are seeing lots of patients with risk factors, and may have been prescribing PrEP already. In a scenario such as this, my messaging focuses more on how to support clinicians in ensuring consistent follow-up with their patients, or in how to deal with multiple risk factors, such as when high-risk sexual behavior may overlap with instances of substance use or homelessness.

For those who are just getting started, it may help to know that even after meeting with 300 providers, I still get nervous each time I prepare to detail, especially if I’m unfamiliar with a practice. Regardless of the nature of my visits, I walk away feeling that I’ve accomplished something if I’ve answered only one question that’s helped the clinician with his or her practice. And I’ve found that in most cases, the people I meet with are very thankful for this service, and are appreciative of the health department. I always thank providers for the work they do and remind them what an important role they have in the community.

Biography. Alyson Decker, NP, MPHAlyson Decker is a Clinical Prevention Consultant and nurse practitioner with Disease Prevention & Control at the San Francisco Department of Public Health. As the branch’s lead academic detailer, she helped develop San Francisco’s first HIV pre-exposure prophylaxis (PrEP) detailing program. Her role consists of detailing with community providers to increase PrEP prescribing in the primary care setting and promote best prescribing practices. In addition, she provides training assistance to healthcare providers and frontline staff around improving sexual healthcare and STD testing and treatment. She also sees patients at the municipal sexual health clinic, San Francisco City Clinic.

This year’s conference is a great chance for everyone interested in AD to learn more, whether you’re part of a long-standing program or just beginning to learn about the versatility and effectiveness of implementing this strategy to improve health outcomes. Our agenda is up, so take a peek, and register if you haven’t yet!

The keynote presentations will provide critical insights for creating and sustaining AD programs in different settings. Dr. Zoe Edelstein will kick off Day 1’s programming, representing the New York Department of Health and Mental Hygiene. This keynote will teach us about their public health detailing intervention to increase use of HIV pre-exposure prophylaxis (PrEP). The New York program was originally founded in 2002, so Dr. Edelstein’s presentation will help anyone from a public health background understand how to both develop and sustain AD, and to adapt it for new and pressing health challenges. ​

Dr. Carol Havens from Kaiser Permanente will provide a detailed overview of the longest-running AD program in the US, a program that was developed with input from Jerry Avorn soon after the original AD studies were published.​​We look forward to being inspired by lessons learned from a leading integrated health care system’s ongoing commitment to improving the quality of care around opioid safety with clinical outreach education.

We’re looking forward to our “Field Presentations” sessions, featuring empiric results from detailers on the ground; expert panelists from the CDC, state departments of public health, and clinical care sharing important impressions on clinician stigma on the critical issues of HIV prevention and opioid safety; and breakout sessions covering many of the practical issues and challenges that detailers face when bringing best evidence to clinicians. Of course, for many of us, the highlight of each conference is the annual update from Jerry Avorn on the state of AD--see his recent blog piece, “Who Do You Trust?” for a preview of what’s to come!

The NaRCAD team is excited by the knowledge that integral opportunities, connections, and partnerships will be created at our unique 2-day event.​ But as excited as our team and our extended community may be about the conference, it’s not the only terrific development underway at NaRCAD this fall. We’ve continued to provide training and support for groups from around the country and the globe, with 2 trainings in the techniques of AD this past September, and more planned this fall and winter! ​Keep your eyes on our Training Series page for the official announcement of our Spring 2018 AD techniques training, and contact us at any time about opportunities and resources to support your AD program.

See you soon,-Mike

Biography. Michael Fischer, MD, MS, NaRCAD DirectorDr. Fischer is a general internist, pharmacoepidemiologist, and health services researcher. He is an Associate Professor of Medicine at Harvard and a clinically active primary care physician and educator at Brigham & Women’s Hospital. With extensive experience in designing and evaluating interventions to improve medication use, he has published numerous studies demonstrating potential gains from improved prescribing.Read more.

As the first and only detailer hired by the Colorado Department of Public Health and Environment, which serves 5.6 million people (about 3 million of which cluster around one metro area), the idea of building a detailing program from the ground up was incredibly exciting…and daunting. From the outset, it was important to determine the place of detailing within the community and establish its fit in the department’s mission.

​Shortly after joining the team, I presented the intended scope of my work at a department meeting--and it generated tremendous interest in the use of academic detailing for public health initiatives far beyond the current planned intervention. This served to solidify the potential value of clinical education outreach to leadership throughout the department. Lessons learned are continually surfacing as we move into year two, and a few key concepts are worth sharing.

​At every opportunity, I presented our detailing goals to community partners and stakeholders, resulting in many connections to medical providers, which, in turn, generated most of our initial provider visits. Submitting articles for local clinical practice newsletters and magazines also established recognition and trust in the state’s new detailing initiatives.

Once provider-facing detailing visits began, two things became quite clear:

Providers crave connection to their public health department.

​Providers want regional data.

In a state with both urban and rural/frontier areas, urban clinicians wanted to be seen as “boots on the ground” to impact large populations by treating their own patients, while rural providers wanted to be acknowledged as part of the team and directed to resources they could access remotely. All clinicians, both urban and rural, wanted the latest disease and health data for their county, zip code, and even census tract level to compare to the rest of the state.

​It has taken multiple attempts to get in the door in many practices. However, after a detailing visit, most providers are outspoken that they found the session worthwhile, and we've used this opportunity to ask for referrals to other providers who might be open to visits. The time investment has also enabled two-way communication allowing us to get a “finger on the pulse” of regional health and disease, particularly in the more rural areas.

The initial time invested to establish relationships with providers was high, but the rate of return has justified the investment. With a new detailing program, the responsibility falls to the detailer to establish credibility, both in resources provided as well as in value for time spent.

If I were starting a detailing program again, or could support new programs who were just getting started, I would love to be armed with these lessons learned:Establish as many protocols, procedures and resources as possible.

Just start! Even if every detail isn’t in place, start visiting with providers. (The steep learning curve of on-the-ground visits is incredibly valuable and will continue to shape and improve your methods.)

Document everything! As methods change and processes improve, document what is changing and why. Document with the goal of sharing not simply a starting point and a finished product but an entire story.

Be willing to adjust in real time. Providers will have varying needs from one to another and from one day to the next, and our flexibility will ultimately strengthen the relationships we are trying to build, allowing academic detailing to have the greatest possible impact.

Biography. Deborah Monaghan, MDPublic Health/Academic Detailer,Colorado Department of Public Health and Environment​Deborah joined CDPHE in 2016 as the Department’s first detailer and currently provides clinical outreach on HIV prevention and sexual health. A graduate of the University of Mississippi School of Medicine, internship took Deborah to Drexel University in Philadelphia, Pennsylvania followed by residency at St Mary’s Hospital in Grand Junction, Colorado. She will complete her MSPH through the University of London School of Hygiene and Tropical Medicine in 2018. Initial response from the provider community receiving detailing has been overwhelmingly positive, and Deborah hopes to facilitate expansion of detailing efforts into other branches of public health to impact more Coloradans.

​#NaRCAD2016 highlights the work of innovators in academic detailing from many locations and organizations, ranging from large national health systems to small independent programs.

​Diverse clinical topics will be featured at our interactive sessions, including pediatric developmental screening, smoking cessation in patients with serious mental illness, opioid misuse and overuse, screening for ADHD, and many others.

​Breakout sessions offer attendees a chance to work closely with leaders in the field, featuring in-depth and hands-on exploration of specific elements of academic detailing. Whether your focus is on training detailers, preparing clinical topic materials, or program evaluation, our dynamic breakout sessions offer a chance to network and acquire new skills.

Our conference is our largest event of the year, but our team has been busy this fall with other activities. At our Boston-based training in September we welcomed trainees from organizations across the country, all of whom concentrated on learning the techniques of academic detailing.

We also spent two days this fall in San Francisco, working with the city’s Department of Public Health on an intervention to increase the use of pre-exposure prophylaxis (PrEP) for patients at risk of contracting HIV. We’re excited to continue supporting our partners at the SFDPH as they move forward on this important initiative.

This year, we know that the opportunity to learn, share ideas, and connect with experts will continue to ignite inspiration for our community’s important work in improving quality of care and patient outcomes in 2017 and beyond.

Biography. ​Michael Fischer, MD, MS | Director, NaRCADDr. Fischer is a general internist, pharmacoepidemiologist, and health services researcher. He is an Associate Professor of Medicine at Harvard and a clinically active primary care physician and educator at Brigham & Women’s Hospital. With extensive experience in designing and evaluating interventions to improve medication use, he has published numerous studies demonstrating potential gains from improved prescribing. Read more.

Highlighting Best Practices

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​NaRCAD is a program of the Division of Pharmacoepidemiology & Pharmacoeconomics [DoPE], Department of Medicine at Brigham & Women's Hospital and Harvard Medical School, and is funded by the Agency for Healthcare Research and Quality [AHRQ].